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Chief Complaint

“My heart feels like it is racing”

History of Present Illness

The patient is presenting with acute atrial fibrillation with a rapid ventricular response.

Student Work-Up

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Missing Information?


Patient Database

Drug Therapy Problems

Care Plan (by Problem)


  1. What underlying etiologies are present in this patient for the development of atrial fibrillation?

    Hint: See Supraventricular Arrhythmias in PPP

  2. How should this patient’s atrial fibrillation be classified?

    Hint: See Supraventricular Arrhythmias in PPP

  3. Should this patient undergo emergent electrical cardioversion at this time?

    Hint: See Supraventricular Arrhythmias in PPP

  4. Should the patient receive a direct oral anticoagulant (dabigatran, rivaroxaban, apixaban, edoxaban) instead of warfarin for prevention of stroke?

    Hint: See Supraventricular Arrhythmias in PPP

  5. Should the patient receive antiarrhythmic drug therapy at this time?

    Hint: See Supraventricular Arrhythmias in PPP


Six weeks later, the patient returns for follow-up. She continues to experience SOB, dyspnea on exertion (DOE), and occasional palpitations. His current vitals reveal a BP of 135/85 mm Hg and a HR of 70 bpm. Today his INR is 2.2 (4 weeks ago, it was 2.5). What antiarrhythmic agent would be recommended for the patient at this time to restore and maintain normal sinus rhythm?


Global Perspective

Non-vitamin K oral anticoagulants (NOACs), also frequently referred to as direct oral anticoagulants (DOACs), are considered first line for stroke prevention in atrial fibrillation guidelines world-wide. For a majority of patients with atrial fibrillation, DOACs are being preferred to warfarin in the majority of patients although warfarin remains the best option for some subsets of patients. While considered to have and improved efficacy/safety ratio as compared to warfarin, the proper use of DOACs requires a carefully considered approach that requires evaluation of several practical aspects of use. Each of the agents (dabigatran, rivaroxaban, apixaban, edoxaban) are approved for use in both the United States (Food and Drug Administration) and the European Union (European Medicines Agency), clinicians need to be cognizant of differences in the labeling for each agent depending on the jurisdiction. For example, in the RELY trial1, both a 150 mg and 110 mg twice daily dose were investigated against warfarin for stroke prevention in atrial fibrillation. However, only the 150 mg dose is available in the U.S., while the 110 mg dose is also available in Europe and other jurisdictions. This distinction is pertinent as it changes available treatment options available to clinicians as the 110 mg may be a preferred option for patients who are at higher ...

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